The goal of palliative care is to improve quality of life for patients with serious and often chronic, life-limiting illness regardless of disease extent or need for additional therapies [1, 2]. Palliative care emphasizes high-quality pain and symptom assessment and management, while incorporating psychosocial and spiritual care focusing on patient/family needs, values, preferences, and cultural beliefs. Palliative care is a philosophy of care that may be delivered by nurses and other health care professionals provided they are educated and skilled through appropriate learning opportunities; it also may be provided by tertiary palliative care specialists to patients with complex problems [3]. It is an important subspecialty that has taken hold in many developed countries over the past three decades; however, a need exists to provide palliative care to all persons globally.

The 2015 Quality of Death Index studied palliative care across the world ranking many Middle Eastern and East African countries at the bottom of the scale [4]. In regard to pain relief, an important component of palliative care, the Global Atlas of Palliative Care suggests access to opioid medications is a substantial problem worldwide [5]. Numerous countries (~ 80%) are not able to provide optimal pain relief for patients at the end of life since they utilize little to no opioids to manage pain. Lastly, access to palliative care is a human right that needs to be formally acknowledged by all countries with a plan for the provision of comprehensive palliative care by appropriately educated nurses and other health care professionals [6].

Nurses are on the frontline of palliative care. More than any other health care professionals, nurses devote the most time caring for patients and family caregivers who are coping with the trials of serious, life-limiting illnesses [7, 8]. Nurses may even be the only contact for patients and families and are in a powerful position to advocate for opioid use and provide patient and family education to dispel myths surrounding opioid use. Additionally, while physicians are in the position to prescribe opioids in many countries, many low- to middle-income countries (LMICs) lack the critical mass of physicians and nurses are the frontline providers of palliative care. In some cases, palliative care is delivered solely by nurses who have been given prescriptive authority in their respective countries (e.g., Uganda) [9]. The role of the nurse also includes advocating for health care policies that impact the delivery of palliative care and the availability of opioids and other essential components of care, providing leadership in community palliative care formation, and in conducting palliative care research [10]. This paper describes an innovative palliative care nursing education program that has been developed, implemented, and sustained in Oman and expanded throughout the Middle East and North Africa. Examples are provided that illustrate tangible outcomes of this collaboration.

Palliative Care in Oman

Early efforts to integrate palliative care in Oman were sporadic and limited. While palliative care content was incorporated into the health professional education curricula, a formal palliative care training program was lacking. In 2011, the Oman Cancer Association (OCA), through support from the Ministry of Health (MOH), collaborated with the Middle Eastern Cancer Consortium (MECC) and the Oncology Nursing Society (ONS) to unite health care professionals from many Middle Eastern countries to build palliative care capacity. Palliative care education was offered to nurses and other health care professionals in the region. Since then, the OCA has exerted great effort in training nurses and other health care professionals in palliative care with the support of its partners (Table 1) [11].

Table 1 Efforts to promote palliative care in Oman

The authors of this paper met during this collaboration and have led this collaboration over the past decade. Professor Michael Silbermann, the Executive Director of the MECC, initially brought this group together and organized the early training efforts. Dr. Al-Zadjali and Ms. Al-Sinawi served as the nursing leaders from Oman, and Ms. Maloney-Newton was a nurse educator from the ONS in the USA since the beginning of the initiative in 2012. Drs. Brant and Fink were brought into the collaborative in 2013 through the Oncology Nursing Society, and Dr. Brant was appointed as leader of the ONS team shortly thereafter. Both Drs. Brant and Fink were appointed to a National Cancer Institute (NCI) committee that represented Palliative Care in the Middle East. Ms. Mushani, a nursing leader and assistant professor in Kenya, entered the collaborative in 2015 when the educational reach expanded into northern Africa. And Dr. Berger taught research course components at a training in 2017. In addition to the meetings in Oman, the authors from this paper and other nurse leaders from this collaborative engaged in education and strategy meetings virtually and in Istanbul and Ankara, Turkey. This nursing collaborative continues to share experiences through social media and through virtual meetings.

Landscape of Oman

The Sultanate of Oman is a Middle Eastern Country located in the southeast coast of the Arabian Peninsula. Oman is approximately 309,500 km2 (i.e., 120,00 mi2) in size with a population around 4.5 million including foreigners and residents. The majority of the population in Oman is young, between 15 and 64 years of age (40% of the population), with a life expectancy of 75 and 79 years for males and females respectively [12]. Oman is an ethnically diverse country and most of the people in the country are Muslim [13]. According to The World Economic Forum, Oman is considered the 9th safest country to live in around the world [14].

The safety of Oman as well as the OCA’s well-developed relationships with international partners, governmental and non-governmental organizations has created an environment that supports palliative care education throughout the East Mediterranean region.

Global Partnerships

Palliative care educational needs are not unique to the Middle East. The World Health Organization (WHO) estimates that at present, palliative care services are only received by 14% of the people who need them with the greatest needs being in low- and middle-income countries such as those of sub-Saharan Africa [15]. The African continent faces the most severe global shortage of health care providers, and estimates needing 4.2 million health care workers to amend the shortfall [16, 17]. Two East African countries, Kenya and Tanzania, reflect the current African situation.

Challenges in the provision of palliative care in Kenya and Tanzania include a lack of adequate health human resources, poor infrastructure, limited access to essential medications, insufficient number of trained palliative care providers, and a lack of palliative care education. Health systems face additional educational challenges including the high cost of utilizing and consulting with expert faculty to teach palliative care concepts or sending local professionals to distant sites for training [16, 17].

The current model of the OCA-ONS partnership is therefore a timely and welcome initiative to meet this challenge. Through this initiative, nurse educators from Kenya and Tanzania were invited to participate in training offered to nurses from Oman and other Middle Eastern countries. The model enabled participants to receive four palliative care courses over 1 year delivered by international oncology and palliative care nursing experts. In addition, participants networked with other regional and international professionals, made new contacts, discussed challenges, exchanged ideas, and received much needed mentorship.

This level of engagement is not always available to participants in their host countries. Episodic workshops delivered by visiting professionals seldom result in long-term sustainability and solid program development. The OCA-ONS initiative with its focus on long-term capacity building enables participants to access training in a stepwise fashion, implement small changes in the workplace, identify issues, and then receive guidance and feedback at future sessions. In this way, they are able to implement more permanent changes in the delivery of palliative care around the region.

The other, perhaps unintended benefit of this partnership is the opportunity for participants to set up networks to exchange knowledge and ideas, establish joint projects, and derive contextually relevant solutions to common challenges. This partnership is an example of how organizations and individuals with a shared vision can partner to impact the lives of patients across several countries, some of which face grave challenges in the provision of palliative care. Ongoing virtual communication has fostered relationships and attainment of goals set during the training.

Palliative Care Curriculum

Nearly 400 nurses and other health care professionals from Oman and 11 countries throughout the Middle East and Eastern Africa have successfully completed palliative care training. The training, conducted by nurses from the Oncology Nursing Society, comprised five separate courses: Foundations of Palliative Care, Advanced Palliative Care, Leadership and Research in Palliative Care, and a Train the Trainer for select representatives from each of the represented countries across the Middle East and northeast Africa.

The Foundations Course delivers basic principles of palliative care and provides nurses with basic knowledge about the definition and scope of palliative care, pain, and symptom management principles; cultural, psychosocial, and spiritual care; the interdisciplinary palliative care team, ethics related to palliative care, and compassion fatigue. The Advanced Course provides in-depth coverage of the same topics as above but also includes family care giving, management of patients with substance use disorders, strategies to increase opioid availability, and how to implement palliative care into the hospital, ambulatory, and home settings. Additionally, the Advanced Course enables nurses to plan and implement evidence-based changes and improvements in palliative care services within their clinical practices, institutions, and communities. A variety of interactive teaching strategies called Liberating Structures are used to meet the learning needs of diverse participants and include facilitated group discussions, case study analyses, role play or improvs, and development and presentation of evidence-based projects. These strategies are used throughout the courses to involve every nurse attendee, unleash creativity, and engage in group problem solving to collaboratively achieve better results than didactic education can achieve alone. An overview of these activities is included in Table 2 [18]. Overall, the Foundations Course is intended to teach the basics of palliative care, while the focus of the Advanced Course is to design palliative care initiatives and programs and develop plans for program implementation within the health care setting or community.

Table 2 Examples of breakout activities in palliative care education

With palliative care being more integrated into the region’s health care systems, the OCA recognized the need to further develop the course participants as leaders in their region, to encourage them to “step up” and lead change, facilitate innovation, and provide advocacy for patients and families. There is also a need for them to contribute to new knowledge through research, and to create a culture of inquiry in which questions are explored and novel interventions tested, with the hope of improving palliative care in the Middle East and East Africa. The research course addresses this need. At the completion of the combined Leadership and Research Course, each participant develops an individual or group research proposal that can potentially be further refined for submission to an Institutional Review Board. Table 3 includes a list of proposed research studies. A leadership development plan is also crafted for personal use and allows nurses and other participants to reflect on their personal leadership strengths and opportunities for improvement.

Table 3 Proposed research questions

After seeing the positive results of the ongoing training and palliative care being implemented in Oman and the surrounding countries, a need existed to make the training sustainable. A “Train the Trainer (TTT) workshop” was thus implemented in February, 2017. The overarching goal was to establish nurse and other health care leaders who would build capacity in their countries by disseminating palliative care knowledge, evidence-based practice initiatives, and bring palliative care research to their respective countries. ONS faculty provided the two-day TTT course for Middle Eastern nurse leaders who had completed all four palliative care courses. These nurses are responsible for carrying forward the mission of progressing palliative care throughout the region.

Following the TTT course, 20 nurse leaders then taught the Foundations of Palliative Care Course to 160 nurses and health care professionals from the region. The course was deemed successful, as evidenced by the impactful presentations from trainees who delivered didactic content of the course and led small group activities. A positive response was garnered from trainees and participants.

Sustainability

Essential to the long-term goal of partnerships between high-income countries and low- to middle-income countries (LMIC) to improve cancer care includes development of a sustainable program [19]. The TTT program which was previously discussed is one sustainability effort. Additionally, programs should include training nurses to deliver palliative care as their full-time practice, which does not always happen in the region. Nurses are often assigned to a variety of units; therefore, they lack specialization in any one area. Service delivery issues, such as a shortage of qualified nursing staff, need to be identified as a health system constraint and addressed in LMICs. For continuity, a long-term relationship among OCA, ONS, and other partners is essential, and a 5-year agreed-upon plan is necessary to solidify the efforts [20]. Relationships are also key in maintaining long-term relationships, and encouragingly, the group maintains contact ongoing through its group WhatsApp chat.

Cancer registries are another essential sustainable effort to collect data that demonstrate useful and reliable information specific to the population of cancer patients who receive palliative care. The creation of a data bank is an important first step in improving cancer care in Middle Eastern countries [21]. If data are collected reliably, summarized, and analyzed by qualified researchers, the information obtained will demonstrate the short-term outcomes and identify strategies needed to achieve long-term goals for sustainability. For sustainability, registries need to be streamlined for efficiency [22]. Additionally, ongoing involvement in the World Health Organization (WHO) palliative care program is important to make progress in cancer prevention and control in the region [23].

Omani, Middle Eastern, and East African nurse leaders are critical to the success of the partnership described in prior sections of this paper. That is the major reason why more than 400 nurses have attended the Palliative Care Nursing and Research and Leadership courses held in Oman in recent years. Each nurse or health care professional returned to their position with new knowledge, skills, and attitudes about palliative nursing care. When disseminating their learning with peers, they influence the current culture of nursing care and help prepare peers for practice changes that can be sustained.

Twenty nurse leaders also completed the TTT course and delivered a four-day Foundations in Palliative Care Course. Mentorship of emerging Omani nurse leaders will continue to occur following these activities, along with other programs to improve cancer and palliative nursing care. Expanding onsite and online programs and opportunities to train nurses to deliver palliative cancer care will positively influence sustainability efforts.

Significant challenges face the ongoing implementation and sustainability of palliative care in Oman and in Middle Eastern, and East African countries. Some of the challenges and suggested solutions are included in Table 4.

Table 4 Palliative care challenges and solutions

Future Directions

Abundant opportunities exist for the future. The OCA-ONS model for palliative care can expand into new regions, including rural areas and sub-Saharan Africa. Primary palliative care should be made available to all persons, and must reach smaller hospitals, home care settings, and clinics throughout Oman and other regions.

In addition to educating nurses, other interdisciplinary team members will be invited to the educational and training opportunities including pharmacists, social workers, spiritual care advisors and chaplains, physicians, and other health care professionals. Interdisciplinary training can enhance teamwork and foster respect for each individual’s role on the palliative care team.

Increasing public awareness of palliative care is another important direction for the future. Patients and health care professionals alike continue to be confused about the definition of palliative care. Ensuring and clarifying that palliative care is not hospice or caring for patients exclusively at the end of life is essential, rather, an understanding should exist that palliative care is care for patients with serious, life-limiting illnesses and their family caregivers.

Finally, leaders should continue to work with governments, ministries of health, and palliative care associations to improve opioid availability for pain management [24, 25]. Other pharmaceuticals are also necessary to improve symptom management and alleviate suffering for patients along the disease trajectory.

Overall, the excitement of this work has permeated the region. While much has been accomplished, much more work remains. As a fourteenth century philosopher noted, “It is important not to allow ourselves to be put off by the magnitude of others’ suffering. The misery of millions is not a cause for pity. Rather it is a cause for compassion.” This compassion will continue to drive these efforts forward and make a positive impact on the quality of lives of patients with serious illness and their families. Under the foundation of MECC and within OCA’s current leadership, continents and people are united to make this dream a reality.